The Hospital Readmissions ReductionProgram (HRRP) requires hospitals to pay penalties if Medicare readmissions
for common diagnosis are too high. Despite
increasing evidence that readmissions are more a result of social factors
largely outside the control of hospitals, readmission rates and penalties are
not risk-adjusted for socio-economic factors. Not surprising given the socio-economics of
the region, safety-net hospitals in the Appalachian region have higher
readmissions and are more likely to receive higher penalties, with hospitals
located in the most distressed counties of the region having the highest rates
and most severe penalties. These results
highlight the importance of risk-adjusting for socio-economic factors for
under-resourced regions and provide insights into the potential impacts of
payment reform on safety-net clinics.
In an effort to control Medicare costs, the Hospital
Readmissions Reduction Program was created as part of the Affordable Care
Act. The program requires hospitals to
pay penalties if readmissions for common diagnosis such as Acute Myocardial
Infarction, Heart Failure, Pneumonia, COPD, and Hip/Knee Replacement are too
high. The HRRP has been levying fines on hospitals since the 2013 fiscal year,
with maximum fines increasing from a 1% reduction in base Medicare Inpatient
claims payment (in 2013) to a 3% maximum reduction in 2015. For fiscal years
2015 and 2016, close to 4 in 5 hospitals in the U.S. were fined for excess
readmissions, though the majority received fines of less than 1%.
The first few years of data from the HRRP have shown that
safety-net hospitals are more likely to receive higher penalties, with data
indicating that factors affecting readmissions are largely outside the control
of hospitals (Gu et al., 2014). This is
particularly troublesome for the Appalachian region, which has higher rates of
poverty, less education, and worse health outcomes when compared to the United
States as a whole (Appalachian Regional Commission, 2015). A recent Kaiser Health News report noted that
four hospitals have received the maximum readmission penalty all four years of
the program, with three of these hospitals located in the Appalachia region (Kaiser
Health News, 2015). For the fiscal year
2016, about one-third of the 38 hospitals receiving the maximum penalty were
located in Appalachia.
Hospital Readmission (FY 2015) &
Dual-Eligible Status (County)
# Hospitals (%)
|
% Dual Eligible (County)
|
% Readmission Rate (Hospital)
|
|
All (Appalachia)
|
475
|
23.0
|
15.7
|
No - Penalty
|
48
(10.1%)
|
21.3
|
14.7
|
Yes - Penalty
|
427
(89.9%)
|
23.2
|
15.8
|
Penalty >= 1%
|
108
(22.7%)
|
25.9
|
16.5
|
Penalty >= 2%
|
32
(6.7%)
|
30.6
|
16.9
|
Penalty = 3%
|
17
(3.6%)
|
32.0
|
17.5
|
Source:
CMS Final Rule MRRP, 2015; CMS Geographic Variation PUF, 2013; Appalachia Data
Portal
Using a
combination of web-based mapping and data visualization tools, we examined
whether hospitals in Appalachia are more adversely affected by the HRRP than
hospitals outside the region. The table
above shows the relationship between hospital readmissions (at the hospital
level) and dual-eligible for Medicaid population (at the county-level). Overall, almost 90% of hospitals in Appalachia
were penalized for excess readmissions in 2015 (compared to about 80% for the
U.S.), with more than 20% receiving fines of 1% or greater. Moreover, hospitals with high readmission
rates were located in counties with higher percentages of dual eligibles, with
the largest fines levied against those hospitals located in counties with dual
eligible populations of greater than 30%. The image below displays the
difference in the percent of dual eligibles for the county in which the
hospitals are located by whether the hospitals received a 2% fine or greater.
Source: CMS Final Rule MRRP, 2015; CMS
Geographic Variation PUF, 2013; Appalachia Readmissions Explorer
There are
also clear geographic patterns within Appalachia. Hospitals with fines of greater than 2% are
concentrated in central Appalachian, which is the most distressed region in
Appalachia, with high rates of poverty and unemployment, and low rates of
education. Further, half of all the
hospitals located in Appalachia that received fines of 3% in 2015 were located
in distressed counties.
Appalachian Regional Commission, County
Economic Status FY2016 (Distressed Counties in Red)
Source: Appalachia Data Portal &
Readmissions Explorer
The Hospital
Readmissions Reduction Program (HRRP) has been criticized for not
risk-adjusting for the socio-economic circumstances of the populations that
they serve, despite increasing evidence of readmissions being driven by factors
largely outside the control of hospitals. While there has been some movement towards
risk-adjusting for socio-economic factors (the National Quality Forum has begun
a two-year pilot studying the potential for risk-adjustment of socio-economic
factors and the U.S. Senate has introduced a bill to incorporate socio-economic
factors), changes to the penalties do not seem imminent. Policy-makers need to consider risk-adjusting
for social determinants of health and geographic variation for hospital
readmissions, while also applying lessons learned when moving towards
value-based payments for physicians and the detrimental impact that not
risk-adjusting may have on safety-net clinics.
HealthLandscape Web-Based Data
Visualization Tools
We used a combination of web-based mapping and data
visualization tools, including the Appalachia Readmissions Explorer and the
Appalachia Data Portal. The Appalachia
Readmissions Explorer is an interactive mapping tool that allows users to
quickly compare readmissions for hospitals in the Appalachian Region. Hospitals are colored red, yellow, or green –
based on whether hospitals have readmissions worse, no different, or better
than national average for all-cause readmissions and for the individual diagnosis
of Heart Failure, Heart Attack (AMI), Pneumonia, COPD, Stroke, and Hip/Knee
Replacements. Mortality data have also
been added which allows users to explore readmissions and mortality rates. Users can also filter by whether a hospital
was fined for excess readmissions in 2015, the percent amount of fine, and by
whether a hospital received a penalty as part of the Hospital Value-Based
Purchasing (HVBP) Program. In addition, users can
use the Stats tool to perform statistical analyses to explore relationships
between hospital readmissions and mortality rates and population health
indicators for the county in which the hospital is located.
The Appalachia Data Portal is an online tool for
exploring demographic, education, income, and health disparities for the 420
counties in the Appalachian region. The data included in the Appalachia Data
Portal come from a variety of sources, including the American Community Survey,
the Appalachian Regional Commission, the Robert Wood Johnson County Health
Rankings, and the Centers for Medicare & Medicaid. The
tool allows users to visualize economic, demographic, and other types of data
for the Appalachian region using maps, graphs, and trend charts. Users
also have the ability to examine the relationship between two indicators (for
example, Diabetes and Poverty) with side-by-side maps and a comparison tool
that uses percentiles to visualize the relationship between variables. The Appalachia Data Portal provides
multiple methods for exploring population indicator disparities throughout the
Appalachian region, and is a helpful tool for identifying health disparities
and bright spots within the region.
Michael Topmiller
Health GIS Research Specialist
HealthLandscape
To access
the Appalachia Data Portal and Appalachia Readmissions Explorer, please visit http://www.healthlandscape.org/AppalachiaDataPortal/map.cfm
More
information about the data sources are available at:
Medicare Hospital Readmissions Reduction
Program:
Appalachia Regional Commission County
Economic Status:
References:
Appalachia Data Portal & Appalachia Readmissions Explorer
Appalachian
Regional Commission (ARC), 2015. County
Economic Status Reports. http://www.arc.gov/appalachian_region/CountyEconomicStatusandDistressedAreasinAppalachia.asp
CMS Final Rule Medicare Readmissions Reduction Program (MRRP), 2015
CMS Geographic Variation Public Use File (PUF), 2013
Gu, Qian,
Lane Koenig, Jennifer Faerberg, Caroline Rossi Steinberg, Christopher Vaz, and
Mary P. Wheatley. 2014. The Medicare Hospital Readmissions Reduction Program:
Potential Unintended Consequences for Hospitals Serving Vulnerable Populations.
Health Services Research, 49(3):
818-833.
Kaiser Health News – “Half of Nation’s Hospitals Fail Again to Escape
Medicare’s Readmission Penalties”
http://khn.org/news/half-of-nations-hospitals-fail-again-to-escape-medicares-readmission-penalties/
